Hockinson Heights Elementary Attestation Form
The safety of our staff, students, and community is our primary concern. To help prevent the spread of Covid-19 and to help reduce the risk of exposure to others, please monitor your student for symptoms and exposure risks related to COVID-19 prior to entering the building. This form should be completed prior to the first of each month. Thank you for your time and cooperation.
In submitting this form, I attest that my child has no symptoms of COVID-19 and has not been in
contact with someone who has COVID-19 symptoms. This form will be kept on file at HHES for the
current month and needs to be re-submitted at the beginning of each month.
If my child does develop symptoms or is exposed to someone who has COVID-19, I will keep him/her home and
contact Hockinson Heights Elementary immediately at (360) 448-6430.
Student Name, First/Last
In what grade is your student?
I agree to check my student daily for the follow symptoms and to keep them home if any symptoms are present. I will contact HHES at 360-448-6430 if my child develops any symptoms.
Temperature of 100.4 degrees or higher or chills
New or worsening frequent, unexplained dry cough
Unexplained shortness of breath or difficulty breathing
Loss of taste or sense of smell
Gastrointestinal issues such as nausea, vomiting or diarrhea
Muscle or body aches
Congestion or runny nose
Has your child been in close contact (6 feet) for longer than 15 minutes, of someone who has tested positive for Covid-19 or who has tested for Covid-19 (and are awaiting test results) due to symptoms associated with Covid-19 in the past 14 days?
Within the past 14 days, has a public health or medical professional told your student or a family member to self-monitor, self-isolate, or self-quarantine because of concerns about COVID 19 infection?
Never submit passwords through Google Forms.
This form was created inside of Hockinson School District.